2019 Drug List Negative Changes Updated 02/26/2019

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1 2019 Drug List Negative Changes Updated 02/26/2019 If you are taking a drug that is removed from the drug list, we will tell you. We will also tell you if we add any restrictions on a drug. We will tell you at least 60 days before we make these changes. This gives you time to talk to your doctor about what to do next. If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the drug list right away. We will also send you a letter telling you that. The table below shows changes made to our 2019 drug lists. Your cost share depends on your coverage stage. Your Drug List tells you the tier that applies to each covered drug. Date of Drug Name Type of Change Possible Alternative Drug(s) Affected Comments Change Drug Lists 1/1/2019 GLEOSTINE CAPS 5 MG N/A 1/1/2019 IPRIVASK SOLR N/A 1/1/2019 ISTODAX SOLR N/A 1/1/2019 ONDANSETRON HYDROCHLORIDE eligibile drug (not on SOLN NSDE) ondansetron hcl 1/1/2019 PEG-INTRON REDIPEN N/A PAK 4 KIT 1/1/2019 POTIGA TABS 300 MG 1/1/2019 RITALIN LA CP24 60 MG N/A methylphenidate hcl cp24 60 mg CA_MMP_2017_NDN_

2 Date of Change Drug Name Type of Change Possible Alternative Drug(s) Affected Drug Lists 1/1/2019 SODIUM CHLORIDE SOLN IV 0.9 % eligible drug (Unapproved drug other) sodium chloride soln iv 0.9% 2/1/2019 AMICAR TABS 500 MG from the formulary. aminocaproic acid tabs or 500 mg 2/1/2019 ANDROGEL GEL MG/1.25GM from the formulary. testosterone gel mg/1.25gm 2/1/2019 ANDROGEL GEL 40.5 MG/2.5GM from the formulary. testosterone gel 40.5 mg/2.5gm 2/1/2019 ANDROGEL PUMP GEL from the formulary. testosterone gel 1.62 % 2/1/2019 DEXTROSE Removed non-part D eligible drug (not on NSDE) Dextrose Inj 50% 2/1/2019 DEXTROSE 50% Removed non-part D eligible drug (not on NSDE) Dextrose Inj 50% 2/1/2019 FINACEA GEL 15% from the formulary. azelaic acid gel 15% 2/1/2019 HYDROMORPHONE Removed non-part D HYDROCHLORIDE eligible drug (not on SOLN 1 MG/ML NSDE) Hydromorphone HCl Inj 1 MG/ML 2/1/2019 MAGNESIUM SULFATE SOLN IJ 50 % 2/1/2019 MENOMUNE-A/C/Y/W- 135 INJ 2/1/2019 METHYLPHENIDATE HCL ER TBCR 2/1/2019 POTASSIUM CHLORIDE SOLN IV 2 MEQ/ML Removed non-part D eligible drug (not on NSDE) magnesium sulfate SOLN IJ 50 % Removed non-part D eligible drug (not on NSDE) N/A Methylphenidate HCl Tab SA OSM 18 MG potassium chloride SOLN IV 2 MEQ/ML Comments CA_MMP_2017_NDN_

3 Date of Change Drug Name Type of Change Possible Alternative Drug(s) Affected Drug Lists 2/1/2019 PRALUENT SOSY 150 MG/ML N/A 2/1/2019 TESTOSTERONE CYPIONATE SOLN 200 eligible drug MG/ML (Unapproved drug other) 2/1/2019 TRELSTAR SUSR 2/1/2019 ZYTIGA TAB 250MG OMEPRAZOLE DELAYED RELEASE TAB 20 MG NORVIR PEGASYS PROCLICK triamcinolone acetonide CLINIMIX 2.75%/DEXTROSE 5% FENOFIBRATE TABS 160 MG amifostine SOLR guaifenesin-codeine LIQD 100MG/5ML- 10MG/5ML from the formulary. NDC's , , removed from formulary testosterone cypionate soln 200 mg/ml TRELSTAR MIXJECT abiraterone acetate tabs Alternative NDCs NORVIR tabs PEGASYS mometasone furoate Nasal Susp 50 MCG/ACT CLINIMIX 4.25%/DEXTROSE 5% TRIGLIDE TABS N/A guaifenesin-codeine Soln MG/5ML Comments for for for for for for for for CA_MMP_2017_NDN_

4 Date of Change Drug Name Type of Change Possible Alternative Drug(s) Affected Drug Lists TETANUS/DIPHTHERI A TOXOIDS- TDVAX SUSP ADSORBED SUSP N/A ketoprofen CAPS 50 MG triamterene & hydrochlorothiazide CAPS 50MG-25MG ADVAIR DISKU AER 100/50 ADVAIR DISKU AER 250/50 ADVAIR DISKU AER 500/50 from the formulary. from the formulary. from the formulary. N/A Fluticasone-Salmeterol Aer Powder BA MCG/DOSE Fluticasone-Salmeterol Aer Powder BA MCG/DOSE Fluticasone-Salmeterol Aer Powder BA MCG/DOSE Comments for for for for for for If you or your doctor disagrees with the change to your drug, you may request an exception. To request an exception, call us at the phone number in the table at the end of this notice. Your doctor must provide a statement to support your request. For details on asking for an exception, check the sections listed below in your Evidence of Coverage or Member Handbook. Plan Name Section Health Net Plan (Medicare-Medicaid Plan) Chapter 9, section 6 If you don t agree with our decision, you may file a complaint with us. To file a complaint, call us at the phone number in the table that follows. You may also send your complaint to us in writing at the address or fax number listed for your plan. State Plan Address, Phone and Fax Number Hours of Operation California Los Angeles County San Diego County CA_MMP_2017_NDN_ Health Net Appeals & Grievances PO Box Van Nuys, CA TTY: 711 Fax: Health Net Appeals & Grievances PO Box Van Nuys, CA TTY: 711 Fax: Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.

5 Health Net Community Solutions, Inc. is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call in Los Angeles County or in San Diego County (TTY: 711) from 8:00 a.m. to 8:00 p.m, Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. ATENCIÓN: Si usted habla español, hay servicios de asistencia de idiomas disponibles para usted sin cargo. Llame al en Los Angeles County y al en San Diego County (los usuarios de TTY deben llamar al 711), de lunes a viernes, de 8:00 a.m. a 8:00 p.m. Después del horario de atención, los fines de semana y los días feriados puede dejar un mensaje. Le devolveremos la llamada el siguiente día hábil. La llamada es gratuita. Health Net Nondiscrimination Notice Health Net Community Solutions, Inc. (Health Net Plan (Medicare-Medicaid Plan)) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net : Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as a qualified interpreters and information written in other languages. If you need these services, contact the Health Net Customer Contact Center at (Los Angeles), (San Diego) (TTY: 711) from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; the Health Net Customer Contact Center is available to help you.

6 You can also file a civil rights complaint with the Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington DC 20201, , (TDD: ). Complaint forms are available at

7 Multi-Language Insert Multi-language Interpreter Services English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call (Los Angeles), (San Diego) (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (Los Angeles), (San Diego) (TTY: 711). Chinese Mandarin: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務請致電 (Los Angeles), (San Diego) (TTY: 711). Chinese Cantonese: 注意 : 如果您說中文, 您可獲得免費的語言協助服務請致電 (Los Angeles), (San Diego) (TTY: 711) Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (Los Angeles), (San Diego) (TTY: 711). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (Los Angeles), (San Diego) (TTY: 711). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (Los Angeles), (San Diego) (TTY: 711). 번으로전화해주십시오. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (Los Angeles), (San Diego) (телетайп: 711). H3237_17_MLI_Accepted_

8 Arabic: Hindi: ध य न द : यदद आप ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (Los Angeles), (San Diego) (TTY: 711). पर क ल कर. Japanese: 注意事項 : 日本語を話される場合無料の言語支援をご利用いただけます (Los Angeles), (San Diego) (TTY: 711). までお電話にてご連絡ください Farsi: Thai: (Los Angeles), (San Diego) (TTY: 711). Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (Los Angeles), (San Diego) (TTY (հեռատիպ) 711): Cambodian: របយ ត ប រ ស នជ អ កន យ យ ភ ស ខ រ, បសវ ជ ន យខ នកភ ស ប យម នគ ត ឈ ល គ ឣ ចម នស រ រ រ ប រ អ ក ច រ ទ រស ព (Los Angeles), (San Diego) (TTY: 711). Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (Los Angeles), (San Diego) (TTY: 711).

9 Punjabi: ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (Los Angeles), (San Diego) (TTY: 711) ਤ ਕ ਲ ਕਰ Laotian: ໂປດຊາບ: ຖ າທ ານເວ າພາສາອ ງກ ດ, ການຊ ວຍເຫ ອດ ານພາສາທ ບເສຍຄ າມພ ອມໃຫ ທ ານ. ກະລ ນາໂທ (Los Angeles), (San Diego) (TTY: 711).

FRM016178CO00 (10/17)

Y0020_18_2827FORM_3836_CHI Accepted 07302017 FRM016178CO00 (10/17) Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin,